If someone mentions a respiratory infection that spreads through droplets and causes fever, coughing, phlegm production and fatigue, the first thing that is likely to come to mind is the SARS-CoV-2 virus that started to plague the world in 2019.
However, the same description is applicable to tuberculosis (TB), a respiratory infection that has been with us for a much longer period of time.
In fact, TB in humans can be traced as far back as 9,000 years ago to the people who once lived in Atlit Yam – a city now under the Mediterranean Sea, off the coast of Israel.
Egyptian mummies dating back to 2400 BCE display skeletal deformities characteristic of TB.
Written records of the disease have also be found from ancient China and India, and it is even described in the Biblical books of Deuteronomy and Leviticus.
The father of modern medicine, Hippocrates (460-370 BCE), described TB as a fatal disease for young adults.
The ancient Greek physician was also able to accurately describe its symptoms and characteristic findings in the lungs.
TB used to cause up to a quarter of all deaths.
The cause was unknown until Dr Robert Koch announced that he had discovered the bacterium that causes TB on March 24, 1882 – a date that has since been declared World TB Day.
The discovery led to further efforts in diagnosing and treating the disease.
The world’s first published randomised controlled trial (the gold standard in medical research) in medicine appeared as a 1948 paper entitled Streptomycin treatment of pulmonary tuberculosis in the British Medical Journal (now known as The BMJ), which paved the way for the modern treatment of TB with antibiotics.
Still a killer
Fast forward to today, and tuberculosis unfortunately remains a killer.
As of 2020, there were approximately 10 million new cases of TB and 1.5 million deaths annually worldwide.
Most deaths were among children under the age of five and adults between 20-35 years old.
Deaths occur disproportionately (over 95%) in low- and middle-income countries, reflecting the role of socioeconomic circumstances in the management of the disease.
TB is also a stark reminder that just because a disease has become endemic, it does not mean that it is any less dangerous or that we can afford to pay less attention to it.
The Covid-19 pandemic has affected us in many ways.
This includes a reversal of the progress made in the fight to end TB.
For the first time in over a decade, TB deaths increased in 2020.
Also, fewer people were diagnosed and treated or provided with TB preventive treatment, and there was a decrease in resources available for essential TB services and research.
A present danger
In Malaysia, many think that TB is a disease of the past.
Unfortunately, it still claims up to 2,000 lives annually in our country, with up to 25,000 new cases recorded every year.
Death from TB increased by 5% in 2020, compared to 2019, while case detection dropped by 10% due to the impact of the Covid-19 pandemic.
The majority of fatalities occurred due to a delay in seeking medical treatment.
This can be due to either complacency or lack of education.
It can be very difficult to ascertain the cause of an infection purely from symptoms alone.
Respiratory infections can be caused by viruses, bacteria or fungi, but they may all have similar symptoms.
In TB, there is usually a combination of lung-related symptoms such as coughing (with or without phlegm, which can sometimes be bloody), chest discomfort and difficulty breathing, alongside more general symptoms like lethargy, fever and weight loss.
These can sometimes occur over a period of weeks to months, as the onset can be insidious in nature.
Diagnosing TB early can be challenging as patients often come to the clinic or hospital late.
Although it most often presents with respiratory symptoms, TB can affect any part of the body, including the lymph nodes, intestines, and even the bones.
Diagnosing it involves imaging of the affected area (e.g. a chest X-ray or a CT scan), followed by efforts to obtain samples from the affected region (e.g. phlegm and tissue).
These samples may be obtained easily (via coughing up phlegm) or may require more invasive methods such as a bronchoscopy or biopsy.
Once collected, the samples will be sent to the laboratory for analysis – there are various tests of differing accuracy that can be used to make a diagnosis.
The introduction of antibiotics – such as streptomycin as mentioned above – was the biggest game changer in the history of TB management.
It changed an incurable, often fatal, disease into one where not only recovery, but also a cure, was possible.
However, the achievements we have made so far are at risk today due to the emergence of antibiotic-resistant TB bacterial strains.
Investing in ending TB
Failure of TB treatment is often a reflection of inadequate socioeconomic policies.
To quote a 2018 study published in the journal Pulmonology: “Socioeconomic status can influence all stages of TB pathogenesis.
“Risk of exposure is related to the underlying disease burden and the environment in which people live.
“People living or working in high burden places are at higher risk of exposure.
“The characteristics of the environment, airflow and number of people sharing the space will influence the risk of exposure.
“Once the TB infection has occurred, increased susceptibility to disease can be related to co-morbidities, but also to malnutrition, alcohol or tobacco abuse.
“Healthcare costs associated with TB are both from direct user fees charged at the healthcare centres and from indirect costs of the visit.
“The money spent on transportation, co-payments for medication, and loss of work due to a medical appointment, are all indirect costs associated with the use of healthcare services.
“These economic barriers may cause a delay in contact with the health system where diagnosis is made, and high costs often constitute a catastrophic economic burden for TB-affected households.”
The theme of World TB Day 2022, i.e. “Invest to End TB. Save Lives”, conveys the urgent need to invest resources in order to continue the war against TB.
On the one hand, the “usual” investment is needed for research, diagnostics and treatment.
However, beyond the medical aspect, there is also a need for more targeted awareness and education campaigns, and more importantly, efforts to reduce the socioeconomic disparity that continues to act as a barrier for healthcare equity.
Malaysia is fully committed to ending TB by 2035 and has developed its National Strategic Plan for Ending TB (2021-2030) in line with the strategies proposed by the World Health Organization (WHO).
This goal will only be realised if we have the will to address TB – and other diseases – in a holistic fashion.
Dr Helmy Haja Mydin is a respiratory physician and chief executive officer of the Social & Economic Research Initiative, a thinktank dedicated to evidence-based policies. For further information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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